This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Monday, 13 July 2009

Admissions and Transfers: NIGHTMARE

I wrote some bits and pieces about what happens when we get an admission and transfer in and old post.

Let me expand on that even more.

We are taking admissions and transfers when we already have way more patients than we can possibly get around too.

They are arriving on my ward when it is convenient for the sending ward to send them. I get a "ball park figure" for when my new patient(s) may arrive. He may come in 5 minutes or 5 hours. That is all I know. I don't know when they are coming. Therefore I cannot organise my time around my other patients to accommodate the new ones.

But that is a mute point. I cannot organise anything. I am trying to accomplish anything I can in the 30-90 second periods of time I have between interruptions. The entire shift is like this. We may be working our assess off, but we are only ever ever hitting on the very top priority things. We are getting the tip of the iceberg chipped away but nothing else.

The patients have this idea that if the nurse is not at their bedside as and when they want her, that she is not caring for them. They have no idea how much goes on behind the scenes, or behind the nurses station really, to keep their ass safe and alive throughout the duration of my shift.

Admissions are sent unexpectedly at mealtimes, during handover, change of shift, when my MI patient has another heart attack stopping me from getting to the cancer patient with the pain medication she has been crying for during the last hour. Unless you are retarded you will understand that the heart attack patient is first priority in this scenario with 02, ecg's, stat orders and organisation for possible transfer to the coronary care unit etc.

If I skim the surface with heart attack man and do the bare minimum to keep him (and my nursing registration) safe from harm then I can get to the cancer patient needing pain killers in 45 minutes. That is 45 minutes if I ignore the other patients crying out for me. IF I don't ignore them, it will be hours before I get to the cancer patient with her pain killers. Setting up her narcotics, checking them for safety and administering them between all the other interruptions takes another 15 minutes.

Where am I now? Oh yes, the admission. And the other patients crying for help and everything else. I go to the admission, walking past multiple voices begging me for help with everything from getting a drink to getting a commode . My new admission and his daughter look at me sharply. "We have been on this ward for nearly an hour and YOU have not bothered to come and check on my father". The other patients are still crying and I really need to check back on my cancer patient to make sure that she is tolerating the narcotics okay and still breathing. They may not be infusing properly because of a kink in the line and she may weep in agony until I get back to her. They might infuse to fast or be too much and she might die. And I will be blamed. Your grandma and ten other people's lovely grandma's are sat weeping in their own urine right now. Right. Back to my admission and his pissed off daughter.

The admission itself is a lot of work and that right there is the crux of this blog post. When these patients come to us they are a fucking mess secondary to a lovely stay on what I term "the sending ward". These wards are called acute medical admission units, short stay medical units, medical admission units, medical assessment units. It is all the same thing really. From here on in I will refer to these places as sending unit hell, or SUH.

They come to us filthy. They come to us in pain with no prescribed pain medication. They send them up with insulin infusing IV. It was ordered to stop 10 hours ago, 10 hours before they were sent to the ward. But it is still infusing without any dextrose etc. The patient has a BM of 1.5. They come up dehydrated with orders for IV fluids prescribed hours ago, yet not started. No venflon is in place. Half the paper work is missing. Trying to figure out what is going on with these people is a mission in itself which can take a lot of time. When these people come, and they come with no warning, I need to leave my other patients and do a bit of assessing and research. Otherwise all hell breaks loose. Most of them are elderly people, who need someone there at all times to ensure that they are clean, hydrated and that their dignity is maintained. If I spend any more than 30 seconds at a time with any one person then all hell will really break loose and I just won't get to see some people.

Sometimes SUH will handover that the patient had bloods done. They were not done. Or that sando k was started yesterday for a low potassium. It was never ordered or given. Last bloods were 36 hours ago and the potassium was 2.1. If I don't contact the medics and let them know that this stuff is going on then they cannot sort it out and treat the patient. It is the nurses legal responsibility to field this crap. SUH tell us that the patient is for an urgent OGD, and that the test was ordered. It was never ordered. Now I have to chase up a doctor to order this test. The patient has been sitting and waiting for this test, and has been starved. The test department doesn't even know he exists. The medic is overwhelmed and cannot get to the ward to order this test for awhile. But the patient again has a dropping HB. Not good. Lots of phone calls and paperwork to sort this nightmare out. And you can bet your ass that it is indeed my problem, with my ass on the line.

They send patients up with the wrong notes, without wristbands, and dump them in the middle of the ward. They send them up as they are taking their last breaths. They have sent septic patients with a low white cell count secondary to chemo without warning, and the porters have dumped him in a dirty bed that has only recently been vacated and not yet cleaned. They did this while I was down the hall in another patients room hanging blood. It was 10 minutes before I saw. I just had to hang that overdue blood then the hca was going to finish ups and our first mission after that was to clean that room. But they couldn't hold off for 10 minutes. They dumped him. Its not like we have any kind of domestic support.

They send them up with dressings and ulcers but no documentation as to how long they have been present and when the dressings were last changed. It is very doubtful that I will have the dressings I need in stock and pharmacy is closed. If this is a Friday it will be Monday before I get those dressings. They send them up without telling us that they are diabetic, or that they are allergic to wheat.

Why does this happen? The nurses in SUH don't have an easy time of it, by any means.. First of all, they have A&E on the phone every 5 seconds demanding that they move people out NOW. Secondly, there are twits with clipboards and magnets constantly up there ass screaming about targets and getting patients moved NOW. With all that going on, it is very doubtful that they ever see their patients for very long and get to sort things out before transfer to the wards. Targets Targets Targets.

They send up confused and wandering fall risk patients without warning, when I and the other staff are already outnumbered by confused, wandering fall risk patients who need one to one supervision. This is often happening while I am trying to help your gran with her tablets, which will then end up on the floor as I go running to hear what that "thump" was. It is the sound of a body hitting the floor. Third time this shift, same person, and a big fat piece of paperwork for me. Those have to be filled in whenever someone falls. No, I do not leave them unsupervised because I want them to fall. You are crazy for even suggesting that.

Then send up violent alcohol detox patients, before I even get the the falling and sick ones. The families come onto the wards with the new admissions and demand to speak to the receiving nurse the second the patient arrives onto the ward. But I am in the middle of a 100 things and people are dying and they are falling and they are shouting out. The family member makes a snotty comment about how "that nurse cannot be bothered speaking to us because gran is old, and they don't care about old people".

The powers that be tell the ward nurses to stop complaining about the screwed up transfers that we are getting. "They have done all the admissions work in SUH, you only need to settle the patients onto the ward".

7 comments:

Welcome back Nurse Anne! Glad to see the bastards didn't get you down enough to stop blogging.

I sympathise with you - I really do. Being one of those clipboard wielding folk, and yes, scrreaming about targets (as I am being screamed at by those above me..and so it continues) I really do see your point. I'm not making myself out to be Florence bloody Nightingale here - but who exactly are these managers of yours that send patients to your understaffed, busy, acute ward without checking whether they're ready/fit/suitable to go? I can't help the admissions unit sending their patients all in one go, HOURS after I've given them the bed, but I sure as hell read the notes, look at the patient and decide whether the receiving ward can cope. That's my job. That's why, despite our bosses thinking that we could manage beds from an office - we can't. We need to walk the wards, see how busy they are, know how many staff they've got on, and make clinical judgements on whether the patient is better off staying where they are than moving. When it gets hideous in A&E, and we're holding ambulances full of sick people in the car park because there's just no space, then I have to say the bar gets lowered, but that is trying to even out the chaos. The point of the patients turning up not cared for is a good one - it happens all to often, and frankly it can't always be blamed on the admissions unit being busy. Sometimes it's just plain bad nursing care, and it's the ward staff who have to pick up the pieces.Before we had admissions units the patients went directly from A&E to the wards, and I remember it being even worse then....what is the answer? It's not all target driven, we are busier than we have ever been, with less people who want to nurse,and less nurses who have good leadership to encourage them to nurse properly.

Granted some of it is down to bad apple nurses. But most of it is down to people being rushed without resources. I get seriously pissed off at the SUH nurses. But everytime they have tried to get me to work down there I have found a way out of it. No way Jose.

I also understand that when there are ambulances in the carpark holding patients that it absolutely means that they need to ship people out of a&e and suh FAST regardless of what is happening on the wards.

I always thought that the a&e targets were a bad idea. IF they wanted to sort out waiting times they should have put money into beds, staff, resources and step down long term care for medically stable healthy elderly patients waiting months for a nursing home placement because they cannot take care of their own basic care. Our wards (medical, surgical, specialty etc) are full of these people and they are very demanding and so are their families. And it causes acutely ill patients to be harmed.

To me, that would have been a much better investment to sort out the bed situation then to sit in a&e with a fucking clipboard.

I meant your bosses are the ones who sit in a&e with a clipboard screaming at the staff when there are no beds etc. I didn't mean you. I wish you worked at my hospital. Some of our bed managers are great and other totally hate us.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.